Histamine Intolerance – Questionnaire
To be completed by the patient:
Disorders since:
Less than four weeks
4 weeks to 6 months
6 months to 1 year
1 year to 5 years
Always or since ________ years
Diet records kept:
Yes
No
Disorders occur after sports/stress:
Yes
No
Increased
Physician’s remarks:
Type of Disorder
Stomach ache
Flatulence
Diarrhoea
Eczema
Itching
Rhinorrhea
Nausea
Severe fatigue
Headache /
Migraine
Occurrence after meals
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
(45 points)
(10 points)
(15 points)
(15 points)
(5 points)
(10 points)
(35 points)
(45 points)
(25 points)
<15 min
<15 min
<15 min
<15 min
<15 min
<15 min
<15 min
<15 min
<15 min
15 min to 3 hours
15 min to 3 hours
15 min to 3 hours
15 min to 3 hours
15 min to 3 hours
15 min to 3 hours
15 min to 3 hours
15 min to 3 hours
15 min to 3 hours
Symptom Score:
Intolerable Foods
Pineapple (-10 pts.)
Seafood (25 pts.)
Eggplant (15 pts.)
Bananas (15 pts.)
Fish (5 pts.)
Cheese (20 pts.)
Fruit juices (-15 pts.)
Red wine (20 pts.)
Salami (5 pts.)
Sauerkraut (20 pts.)
>3 hours
>3 hours
>3 hours
>3 hours
>3 hours
>3 hours
>3 hours
>3 hours
>3 hours
Points
Acid-containing foods
i.e. vinegar (-5 pts.)
Chocolate (10 pts.)
Sparkling wine (25 pts.)
Tomatoes (10 pts.)
Food Score:
Hit-Score:
Points
Points
Physician’s remarks:
HISTAMINE IN STOOL
INSTRUCTIONS FOR STOOL SAMPLE COLLECTION (please follow instructions carefully)
Please use the enclosed stool collector to collect the sample. Make sure that the stool specimen does
not come in contact with water or urine.
Take the stool tube and remove the sampling rod with white tip by turning it left 90°.
Take the sample with the white rod by sticking the tip into the stool. Make sure that the tip is
filled before removing it.
Put the sampling rod into the tube again. Close the tube tightly to avoid leakage.